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Increased Intracranial Pressure

Increased Intracranial Pressure. Mary Ann Reilly BSN, MS, CRRN Santa Clara Valley Medical Center, Rehab Nurse Manager.

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Increased Intracranial Pressure

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  1. Increased Intracranial Pressure Mary Ann Reilly BSN, MS, CRRN Santa Clara Valley Medical Center, Rehab Nurse Manager

  2. In 2004 the SJ Mercury wrote: "As he was giving his speech he stumbled slightly and then he started to perspire a bit. I thought almost immediately that something is not right.“ • His repeated vomiting prompted paramedics to treat him with oxygen and monitor his heart for half an hour -- routine care for a sudden food-borne illness

  3. The initial suspicion that Mayor Ron Gonzales had food poisoning Wednesday night shows just how difficult some strokes are to detect -- and experts say it offers a warning to people who might find themselves with similar symptoms.

  4. Gonzales' type of stroke is called an intraventricular hemorrhage. • This means that a blood vessel had broken and was leaking into the ventricle, which carries spinal fluid.

  5. So what’s the big deal? • Skull

  6. Components of Cranial Vault • Meninges • Dura • Arachnoid • Pia • Brain • Brain tissue 80-88% • Blood • Blood 2-11% • CSF • CSF 9-10%

  7. http://learntech.uwe.ac.uk/neuroanatomy/neuro4_1.htm

  8. Blood • 15-20 of the cardiac output • 20-25% of all oxygen inspired • 750cc/min • 80% from carotid arteries • 20% from vertebral • Circle of Willis is collateral circulation • No sugar/fat/oxygen storage

  9. Autoregulation • When intra-cranial pressure begins to rise, the body’s own compensatory mechanisms include decreasing the production of CSF and restricting the blood flow to the brain(by vasoconstriction).

  10. Autoregulation • Self Regulated • PCO2 (carbon dioxide) vasodilator • For every 1mmHg change in PCO2 there is a 1-2cc change in blood flow per 100 GMs of brain • (1300-1400Gms avg. wt.) =s [750 +65] or [750 + 130] • Diameter of vessels • Hypercapnia: Increases CBF • Hypocapnia: Decreases CBF

  11. Intercrainial Pressure Regulation • When BP increases, cerebral arterioles constrict to keep blood entering brain at steady rate. • When BP falls, cerebral arterioles dilate to increase blood flow to brain

  12. Intercrainial Pressure Regulation • Metabolic regulation—changes in O2 and CO2: Low O2 and increased CO2 cause vasodilation CSF regulation—decreased production or increased reabsorption decreases ICP.

  13. Factors Affecting CBF • Viscosity of the blood • Seizures • Anemia • Drugs

  14. CSF • 125-150 cc clear fluid • 500cc produced per day • 20cc per hour • Replaced 4-7 times per day • Function • Protection, cushions • Waster disposal • Nutritional support (2/3 bodies BS)

  15. CSF Pressure • Norm • 1-15 mmHg or <200mm H2O • Low pressure • Dehydration • Increased pressure • Val Salva,Tumor, Subdural Hematoma, Subarachnoid Hemorrhage, Infections, Hydrocephalus

  16. Symptoms of Increasing ICP • Headache • Visual changes • Nausea • Vomiting • Behavior changes • Changes in LOC • Seizures

  17. Symptoms • Aniscoria • Hemiparesis • Vital sign changes • Cushing Triad

  18. http://learntech.uwe.ac.uk/neuroanatomy/neuro4_4.htm

  19. Cushing’s Triad • Vital Sign Changes in ICP— • Systolic pressure increases (widened pulse pressure results). • Slowing of heart occurs—bradycardia (occurs as result of reflexive slowing in response to increased systolic pressure) • Respiration changes—becomes slowed

  20. Could it be? • Difficulty speaking • Blurred vision • Hypertension • Shallow rapid breathing • Visual disturbances • Paresthesia • Hypoglycemia

  21. OR? - Confusion • Lethargy • Nausea & Vomiting • Coma • Seizures • Syndrome of Inappropriate ADH

  22. OR? • Changes in LOC • Nausea & Vomiting • Irritability • Disorientation • Personality changes • Seizures • Fluid Overload

  23. OR? • Street drug • Alcohol withdrawal • Over dose • Diabetic ketoacidosis • Hypervitiaminosis A • Drug • www.merck.com/mrkshared/mmanual/section1/chapter3/3c.jsp

  24. Diagnosis of Increased Intracranial Pressure • Overt symptoms • Papilledema • Nuchal rigidity • Lumbar Puncture***

  25. Lumbar Puncture • Contraindicated • Focal signs • Intracranial mass • Papilledema • Cardiorespiratory compromise • Infection of skin

  26. Rational for Contraindication • A simple analogy Performing a LP in the presence of I-ICP, may result in herniation

  27. Herniation • Tentorium • Midbrain and diencephalon through the tentorium • Uncal • Tonsillar • Cerebellar tonsils through the foramen magnum

  28. Diencephalic Stage • Confused and drowsy • Constricted pupils • Gaze palsies

  29. Mesencephalic Stage: • Unconscious • Decerebrate posturing • Dilated pupils • Hyperventilation

  30. Pontine Stage • Unconscious • Decerebrate posturing • Constricted pupils • Irregular breathing

  31. Decorticate posture • Indicated by rigidity, flexion of the arms, clenched fists, and extended legs. The arms are bent inward toward the body with the wrists and fingers bent and held on the chest. Presence of this type of posturing implies severe damage to the brain with immediate need for medical attention.

  32. Decerebrate Posturing • Internal rotation and extension of the arms & lower limb extension • Due to midbrain compression as the brainstem is further compressed

  33. Medullary Stage • Unconscious • Flaccid • Loss of homeostatic control: • Increase heart rate • Decrease blood pressure • Hyperthermia • Cheyne-Stokes breathing

  34. Cheyne-Stokes • Breathing describes a waxing and waning ventilation, sometimes with periods of apnea, that occur in cycles. • It is due to a delay in the medullary chemoreceptor response to blood gas changes

  35. 1893 http://thediagram.com/3_6/

  36. Common Causes of I-ICP • Vascular abnormalities • AV malformations, aneurisms, stroke • Diffuse cerebral ischemia • Closed head trauma, shaken baby, vasospasm • CNS infections • Tumors • Trauma • Obstruction of CSF flow

  37. Hydrochepalus

  38. Intra Cerebral Hemorrhage

  39. AV Malformation

  40. Crainal Defect

  41. Crainial defect with midline shift

  42. The Monroe-Kelle Hypothesis states that an increase in the volume of one component (blood, brain tissue, CSF) must be accompanied by a decrease in another component if intracranial pressure is to remain constant. The CSF and blood volume are the compartments that most easily change to accommodate changes in pressure.  Interventions to prevent secondary brain injury follows these principles and focuses primarily on cerebral blood flow and drainage. 

  43. Management / Trauma • Rapid transportation • Early intubation • Aggressive resuscitation • Immediate CT • ICP monitoring

  44. CAT Scans • Sensitivity for visualizing blood approximately 96% • Visualizes • Fractures • Hematomas

  45. Operative Management • Burr holes • Intra-operative ultra sound • Surgical evacuation of mass lesion • Craniotomy • Craniectomy • Ventricular drainage http://www.trauma.org/neuro/neuromonitor.html

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